Evaluation of an Emergency Department Lean Process Improvement Program to Reduce Length of Stay

In recent years, lean principles have been applied to improve wait times in the emergency department (ED). In 2009, an ED process improvement program based on lean methods was introduced in Ontario as part of a broad strategy to reduce ED length of stay and improve patient flow. This study seeks to determine the effect of this program on ED wait times and quality of care. We conducted a retrospective cohort study of all ED visits at program and control sites during 3 program waves from April 1, 2007, to June 30, 2011, in Ontario, Canada. Time series analyses of outcomes before and after the program and difference-in-differences analyses comparing changes in program sites with control sites were conducted

Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada

Objective To determine whether patients who are not admitted to hospital after attending an emergency department during shifts with long waiting times are at risk for adverse events

Genetics University of Toronto Thrombophilia Study in Women (GUTTSI): genetic and other risk factors for venous thromboembolism in women

BACKGROUND: Women may be at increased risk for venous thromboembolism (VTE) as compared with men. We studied the effects of genetic and biochemical markers of thrombophilia in women, in conjunction with other established risk factors for VTE. METHOD: The present retrospective case-control study was conducted in a thrombosis treatment programme at a large Toronto hospital. The cases were 129 women aged 16-79 years with objectively confirmed VTE. Age-matched control individuals were women who were free of venous thrombosis. Neither cases nor control individuals had known cardiovascular disease. Participants were interviewed regarding personal risk factors for VTE, including smoking, history of malignancy, pregnancy, and oestrogen or oral contraceptive use. Blood specimens were analyzed for common single nucleotide polymorphisms of prothrombin, factor V and methylenetetrahydrofolate reductase (MTHFR; C677T, A1298C and T1317C), and the A66G polymorphism for methionine synthase reductase (MTRR).Fasting plasma homocysteine was also analyzed. RESULTS: Women with VTE were significantly more likely than female control individuals to carry the prothrombin polymorphism and the factor V polymorphism, or to have fasting hyperhomocysteinaemia. Homozygosity for the C677T MTHFR gene was not a significant risk factor for VTE, or were the A1298C or T1317C MTHFR homozygous variants. Also, the A66G MTRR homozygous state did not confer an increased risk for VTE. CONCLUSION: Prothrombin and factor V polymorphisms increased the risk for VTE in women, independent from other established risk factors. Although hyperhomocysteinaemia also heightens this risk, common polymorphisms in two genes that are responsible for homocysteine remethylation do not. These findings are consistent with previous studies that included both men and women

A National Concept Dictionary

Overall objectives or goal Most of the organizations that use population administrative data for research purposes have internal repository of validated definitions and algorithms of their own. Many of these concepts and definitions are applicable or at least adaptable to other organizations and jurisdictions. A comprehensive National (and potentially International) Concept Dictionary could help investigators to carry out methodologically sound work using consistent and validated algorithms using a shared pool of knowledge and resources. The Institute for Clinical Evaluative Sciences (ICES) in Ontario, Canada has recently modernized its internal Concept Dictionary by adopting standard templates based on the Manitoba Centre for Health Policy (MCHP) Concept Dictionary, reviewing and updating existing content and tagging the concept entries with appropriate MeSH terms and data sources, and adding standard computer code (e.g., SAS coding) where appropriate. A SharePoint® web-based application has been developed to provide advanced tagging, searching and browsing features. We envision a wiki-based Concept Dictionary hosted on a cloud-based environment with very granular access controls to provide enough flexibility for each participating organization to control their own content. This means each organization will be able to decide on how to share their own concepts (or part of them) with the public or internal users. All content will be tagged with MeSH terms and as well with the organization’s name that initially posts each entry. Other organizations which find the same concept applicable to their own use can tag the same entry with their organization name or refer to a secondary adapted entry if adaptation to fit their data and methodologies is required. The Search feature will allow refining the search criteria by MeSH terms, data sources, and also organization/jurisdiction name. Multiple layers of access controls will allow each organization to have their own groups of users with different standard privileges such as Local Administrators, Authors and Approvers (or Publishers). The Approver (Publisher) users within each organization can publish each entry for internal or public view. This way, for example, a definition/algorithm can be viewable only within the organization until the validation process is complete, and then the entry can be made publically available, while some sections, such as computer code, can remain restricted to the organization. We will discuss challenges in developing and maintaining such a platform including the costs, governance, intellectual property rights, copyrights and liabilities for the participating organizations. The intended output or outcome We aim to use this opportunity to form a working group from the interested organizations that are ready to participate and commit in developing this collaborative platform. After the conference, there will be follow up sessions with the members of the working group to plan and develop the online application

Risk of Fetal Death Associated With Maternal Drug Dependence and Placental Abruption: A Population-Based Study

Abstract Objective: Substance use in pregnancy is associated with placental abruption, but the risk of fetal death independent of abruption remains undetermined. Our objective was to examine the effect of maternal drug dependence on placental abruption and on fetal death in association with abruption and independent of it. Methods: To examine placental abruption and fetal death, we performed a retrospective population-based study of 1 854 463 consecutive deliveries of liveborn and stillborn infants occurring between January 1, 1995 and March 31, 2001, using the Canadian Institute for Health Information Discharge Abstract Database. Results: Maternal drug dependence was associated with a tripling of the risk of placental abruption in singleton pregnancies (adjusted odds ratio [OR] 3.1; 95% confidence intervals [CI] 2.6-3.7), but not in multiple gestations (adjusted OR 0.88; 95% CI 0.12-6.4). Maternal drug dependence was associated with an increased risk of fetal death independent of abruption (adjusted OR 1.6: 95% CI 1.1-2.2) in singleton pregnancies, but not in multiples. Risk of fetal death was increased with placental abruption in both singleton and multiple gestations, even after controlling for drug dependence (adjusted OR 11.4 in singleton pregnancy; 95% CI 10.6-12.2, and 3.4 in multiple pregnancy; 95% CI 2.4-4.9). Conclusion: Maternal drug use is associated with an increased risk of intrauterine fetal death independent of placental abruption. In singleton pregnancies, maternal drug dependence is associated with an increased risk of placental abruption. Résumé Objectif : Bien que la consommation d'alcool et de drogues au cours de la grossesse soit associée au décollement placentaire, le risque de mort foetale n'étant pas associé à ce dernier demeure indéterminé. Notre objectif était d'examiner l'effet de la dépendance de la mère aux drogues sur le décollement placentaire, ainsi que sur la mort foetale attribuable à ce dernier et sur la mort foetale n'y étant pas attribuable. Résultats : La dépendance de la mère aux drogues a été associée à un risque triplé de décollement placentaire dans le cas des grossesses monofoetales (rapport de cotes [RC] corrigé, 3,1; intervalle de confiance [IC] à 95 %, 2,6-3,7), mais non pas dans celui des grossesses multiples (RC corrigé, 0,88; IC à 95 %, 0,12-6,4). La dépendance de la mère aux drogues a été associée à une hausse du risque de mort foetale n'étant pas attribuable au décollement (RC corrigé, 1,6; IC à 95 %, 1,1-2,2) dans le cas des grossesses monofoetales, mais non pas dans celui des grossesses multiples. Le risque de mort foetale connaissait une hausse en présence d'un décollement placentaire, tant dans le cas des grossesses monofoetales que dans celui des grossesses multiples, et ce, même à la suite de la neutralisation de l'effet de la dépendance aux drogues (dans le cas des grossesses monofoetales : RC corrigé, 11,4; IC à 95 %, 10,6-12,2; dans celui des grossesses multiples : RC corrigé, 3,4; IC à 95 %, 2,4-4,9). Méthodes Conclusion : La consommation de drogues par la mère est associée à une hausse du risque de mort foetale intra-utérine, peu importe la présence ou non d'un décollement placentaire. Dans le cas des grossesses monofoetales, la dépendance de la mère aux drogues est associée à une hausse du risque de décollement placentaire

Evaluation of an emergency department lean process improvement program to reduce length of stay

Study objective In recent years, lean principles have been applied to improve wait times in the emergency department (ED). In 2009, an ED process improvement program based on lean methods was introduced in Ontario as part of a broad strategy to reduce ED length of stay and improve patient flow. This study seeks to determine the effect of this program on ED wait times and quality of care. Methods We conducted a retrospective cohort study of all ED visits at program and control sites during 3 program waves from April 1, 2007, to June 30, 2011, in Ontario, Canada. Time series analyses of outcomes before and after the program and difference-in-differences analyses comparing changes in program sites with control sites were conducted. Results In before-after models among program sites alone, 90th percentile ED length of stay did not change in wave 1 (–14 minutes [95% confidence interval {CI} –47 to 20]) but decreased after wave 2 (–87 [95% CI –108 to –66]) and wave 3 (–33 [95% CI –50 to –17]); median ED length of stay decreased after wave 1 (–18 [95% CI –24 to –12]), wave 2 (–23 [95% CI –27 to –19]), and wave 3 (–15 [95% CI –18 to –12]). In all waves, decreases were observed in time to physician assessment, left-without-being-seen rates, and 72-hour ED revisit rates. In the difference-in-difference models, in which changes in program sites were compared with controls, the program was associated with no change in 90th percentile ED length of stay in wave 2 (17 [95% CI –0.2 to 33]) and increases in wave 1 (23 [95% CI 0.9 to 45]) and wave 3 (31 [95% CI 10 to 51]), modest reductions in median ED length of stay in waves 2 and 3 alone, and a decrease in time to physician assessment in wave 3 alone. Conclusion Although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared with that of control sites, which were exposed to system-wide initiatives such as public reporting and pay for performance. This study suggests that further evaluation of the effectiveness of lean methods in the ED is warranted before widespread implementation

Impact of health-related behavioral factors on participation in a cervical cancer screening program:the lifelines population-based cohort

BACKGROUND: Regular participation in cervical cancer screening is critical to reducing mortality. Although certain sociodemographic factors are known to be associated with one-time participation in screening, little is known about other factors that could be related to regular participation. Therefore, this study evaluated the association between health-related behavioral factors and regular participation in cervical cancer screening.METHODS: The Lifelines population-based cohort was linked to data for cervical cancer screening from the Dutch Nationwide Pathology Databank. We included women eligible for all four screening rounds between 2000 and 2019, classifying them as regular (4 attendances), irregular (1-3 attendances), and never participants. Multinomial logistic regression was performed to evaluate the association between behavioral factors and participation regularity, with adjustment made for sociodemographic factors.RESULTS: Of the 48,325 included women, 55.9%, 35.1%, and 9% were regular, irregular, and never screening participants. After adjustment for sociodemographic factors, the likelihood of irregular or never screening participation was increased by smoking, obesity, marginal or inadequate sleep duration, alcohol consumption and low physical activity, while it was decreased by hormonal contraception use.CONCLUSION: An association exists between unhealthy behavioral factors and never or irregular participation in cervical cancer screening.</p

Nurse practitioners’ perceptions of their ability to enact leadership in hospital care

Aims and objective: To gain insight into nurse practitioners’ (NP) leadership roles in Dutch hospital care, by exploring the perceptions regarding their current leadership role and the differences with their previous role as a registered specialised nurse. Background: To meet today's challenges of the increasing healthcare demands, the employment of NPs is proliferating. NPs have the ideal position to play a pivotal role within healthcare reforms, yet full expansion of their scope of practi

Lessons learned from a living lab on the broad adoption of eHealth in primary health care

Background: Electronic health (eHealth) solutions are considered to relieve current and future pressure on the sustainability of primary health care systems. However, evidence of the effectiveness of eHealth in daily practice is missing. Furthermore, eHealth solutions are often not implemented structurally after a pilot phase, even if successful during this phase. Although many studies on barriers and facilitators were published in recent years, eHealth implementation still progresses only slowly. To further unravel the slow implementation process in primary health care and accelerate the implementation of eHealth, a 3-year Living Lab project was set up. In the Living Lab, called eLabEL, patients, health care professionals, small- and medium-sized enterprises (SMEs), and research institutes collaborated to select and integrate fully mature eHealth technologies for implementation in primary health care. Seven primary health care centers, 10 SMEs, and 4 research institutes participated. Objective: This viewpoint paper aims to show the process of adoption of eHealth in primary care from the perspective of different stakeholders in a qualitative way. We provide a real-world view on how such a process occurs, including successes and failures related to the different perspectives. Methods: Reflective and process-based notes from all meetings of the project partners, interview data, and data of focus groups were analyzed systematically using four theoretical models to study the adoption of eHealth in primary care. Results: The results showed that large-scale implementation of eHealth depends on the efforts of and interaction and collaboration among 4 groups of stakeholders: patients, health care professionals, SMEs, and those responsible for health care policy (health care insurers and policy makers). These stakeholders are all acting within their own contexts and with their own values and expectations. We experienced that patients reported expected benefits regarding the use of eHealth for self-management purposes, and health care professionals stressed the potential benefits of eHealth and were interested in using eHealth to distinguish themselves from other care organizations. In addition, eHealth entrepreneurs valued the collaboration among SMEs as they were not big enough to enter the health care market on their own and valued the collaboration with research institutes. Furthermore, health care insurers and policy makers shared the ambition and need for the development and implementation of an integrated eHealth infrastructure. Conclusions: For optimal and sustainable use of eHealth, patients should be actively involved, primary health care professionals need to be reinforced in their management, entrepreneurs should work closely with health care professionals and patients, and the government needs to focus on new health care models stimulating innovations. Only when all these parties act together, starting in local communities with a small range of eHealth tools, the potential of eHealth will be enforced